INsite ruled legal - Supreme Court unanimous decision

The surpreme court has unanimously affirmed the BC court of appeals decision that INsite is a health facilty and directed that the Minister of Health grant an exemption to drug laws. http://scc.lexum.org/en/2011/2011scc44/2011scc44.html 

Some key quotes from the decision:

"The Minister’s decision, but for the trial judge’s interim order, would have prevented injection drug users from accessing the health services offered by Insite, threatening their health and indeed their lives."

"during its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.  The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.

"On future applications, the Minister must exercise that discretion within the constraints imposed by the law and the Charter, aiming to strike the appropriate balance between achieving public health and public safety.  In accordance with the Charter, the Minister must consider whether denying an exemption would cause deprivations of life and security of the person that are not in accordance with the principles of fundamental justice.  Where, as here, a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety, the Minister should generally grant an exemption."

Great news for INsite and hopeful news for other Canadian cities that have come to value the benefit that Vancouver has achieved through the presence and utilization of the safe injection site.

The question of the day, will the current government willingly recognize and permit the utilization of other facilties?   A smart government wanting to win the war on drugs, will acknowledge that successful drug policy includes harm reduction and treatment - something that supervised injection provides, or at least provides the avenue to rehabilitation. 

Now, is the current government smart enough to see this?

Breastfeeding and brain development - A public health success to savour

Please send messages to drphealth@gmail.com, and follow on twitter @drphealth

Children are our greatest resource. It still amazes me how often governments can treat children as an afterthought since they hold minimal political value.   That will only change when every person, including children are given a vote. (Speaking of which, kudos to Saudi Arabia for granting women the right to vote and run for office – and reminding us in Canada how privileged we currently are)

 One of the key determinants of health is early childhood development.  We know that from conception,  affects on the mother can positively or negatively impact growth of the fetus.  Brain development occurs mostly in the first 2 years of life, slowing down as we prepare our children to start school. 

If you miss the irony of this statement -  go back to birth.

In this simplified view of the multiple aspects of brain development, note that the central line is at age 1, and after that point all higher brain functions decrease their rate of growth.  

It should not be surprising that schools that score well on geographic comparisons of test results tend to be located in areas of relative socioeconomic prosperity.  Children with enriched infancy where parents can focus on nourishment through good feeding, stimulating play, social interaction and emotional warmth stand a far better chance of success in later years.   Those children who are prepared for school, not surprisingly, are the children who do well at school.   The inequities in school success are engrained before the formal education “system” greets the child as they walk into those hallowed hallways for their first time.  

Can we shift our focus to attention around the first year of life, and not just ensure immunizations are completed?  There are other successes as well.

National Breastfeeding Week is October 1- 7.  There are many benefits to breastfeeding beginning with both physical and emotional nourishment.  Initiation rates (Figure 1 in the link) in Canada are nearly 90% and have gradually moved upwards over the past decade.  Breastfeeding rates in Canada 2001-2009 .  The best news that we need to reflect upon, is at its lowest point in the early 1960’s, breastfeeding initiation was only about 25% with rates in Quebec as low as 10%.  Here is a huge public health success that has been lost in the debates of year to year recent history and a culture of support for breastfeeding that needs to create an urgency to remain active. Over the past 50 years, or just two generations, a full reversal of culture has occurred.  This exceeds any other public health success that comes to mind. 

The more recent and appropriate gains have been made in sustaining breastfeeding through the full first six months of life (Figure 2 in the above link).  Rates are currently only 25% of the current recommendation – and needs to be the focus of breastfeeding programs designed to support women through the full first 6 months. The best practices are in BC at33%.  Nova Scotia needs to redouble its efforts with current rates of only 13% at 6 months.

 Public health workers should take note that the medicalization of clinics designed to support a small percentage of women with breastfeeding pathology may be a barrier to efforts to achieving where the greatest benefit lies – in encouraging and supporting all families to breastfeed for the minimum of six months, and to do so without alienating and imposing guilt upon those that have not yet appreciated the shifting cultural tide.  

Drphealth turns 1000 pages. INsite court decision soon. Its election time?

Today is also a big day for the blog – some lucky reader will be the 1000^th hit to the site.  Sorry no prizes for the lucky person and tracking won't be able to say who that person is.  The relative success of sharing Canadian public health stories speaks to a need. 

In keeping with good public health practice and evaluating the efforts, some interesting facts from what I can gleam and happy to share with you. 

10% of the visitors in the past month have been good neighbours to the south.  Welcome to the cloistered life of the Canadian public health worker. 

The most popular page is on the issue of health equity south of the border and Gini Coefficient. 

Visitors have come from 10 countries, with France and Russia running a distant 3^rd to the US. Canadian visitors who are the main target appropriately constitute 90% of the following.   

Only a handful of people have signed up for Tweets (@drphealth) and no one has used the following feed feature (at the lower left corner).   The retweets through the Linked-IN professional network are the largest single social media source driving people to the website.  As most people seem to access the site directly, I am thankful to those that are following.

As with many blogs, there may be lots of readers but only a very small number willing to actually put their words to a comment.   I have received more emails than posted comments (drphealth@gmail.com), but still just a handful. Rest assured I will maintain your confidiality as well. Join the dialogue, it is the way the public health community will thrive. Your feedback on the blog, on any issue, and suggestions for topics are all welcomed. 

INsite decision soon.

The rumour mill is starting to buzz.  The Supreme Court decision on INsite may come out in the next week.  Jump back to August 3 blog Insights into Insite   to review the background.  It is a substantive issue for the public health community that pits public health against the government of the day and no one looks good. No doubt the fight has caused negative repercussions throughout the public health community.  It is interesting timing as the government continues to promote its 'get tough on crime' and 'lock up the drug users’' agendas.   It might signal a loss for the government and need to regroup, or it may retrench their blinders. My bet is for the later and more troubled waters ahead.  Stay tuned.

Provincial elections

Advocacy begins with you.  

PEI and NWT go the polls October 3^rd

Manitoba October 4^th

Ontario October 6^th

Newfoundland and Labrador and the Yukon October 11^th

Saskatchewan Nov 7^th

Quebec, Nunavut and Alberta  probably in 2012. 

I think our friends in BC are starting a guessing lottery and could slip in the queue sometime.

Can anyone make public health an issue on the political agenda?    What questions can you find to ask candidates? A good resource is the CPHA policy website at http://www.cpha.ca/en/programs.aspx .  CPHA also put out a guide for candidates questions for the spring national election, I could not locate it and seems so relevant now. 

Public Health News Headlines. Jail, antibiotics, sex, tobacco and air

Monday’s always seem full of public health news headlines

1.      Groups opposing mandatory minimum sentencing

2.      Canada has some of the cleanest air in the global – but still affects thousands of Canadians

3.      Alternatives to antibiotics sought for farm animals

4.      More persons having unsafe sex

       And in the email box, a notice on the national consultation process for the Federal Tobacco Control

The previous blog article spoke to the insistent perversion of the current government to impose mandatory minimum sentencing when health advocated, judicial experts and rehabilitation specialists speak openly against the utility of such legislative strategies.  Mandatory Minimum sentencing a waste of wallet.

A WHO report on air quality ranked Canada and Australia tied for 3^rd amongst 80 countries for the quality of air.   A subject that this blog will have to come back to.  Canada has some marvelous air quality scientists and was the first country to use a multipollutant approach to assessing air quality as it negatively affects health.

CBC is running a piece following an “announcement” on Marketplace that the federal government will invest $4 Million in looking to address antibiotic use in farm animals.   The good news is the government responded to the actions of  the media in forcing transparency.  The bad news is neither the government nor the CBC read the blog AMR and livestock Kicking the cat or for that matter the government has only minimally taken the advise by their own expert advisory panel report from almost 10 years ago now.  

 A pharmaceutical company sponsored study for today as World Contraception Day shows that increasingly sex with new partners is without any form of contraception in the developed world.  Press release Clueless or Clued up.  Some developing countries appear to be doing better with sex education.  Regrettably Canada was not part of the survey.   It does go to show that sometimes Big Pharma can be involved in some good work.

Finally, the federal government is calling for input on a one year federal tobacco control plan.   Tobacco Control Strategy consultation  What caught my eye most, was the initiative led by Health Canada, includes partnering with Public Safety, RCMP, Revenue Canada, Border Services and Public Prosecutions.  Of course Canada should be proud of its accomplishments to date in reducing smoking in this country.  Peak levels in the high 30% range have decreased to 17% and Canada has outperformed many developed countries in reducing tobacco use.  The emphasis of the strategy is on enforcement through penalizing those that sell to minors,  cracking down on smuggling, cracking down on counterfeiting, restricting advertising and at least making tobacco less attractive.  Missing of course are efforts to support a smoke free lifestyle, educational activities, cessation support and targeted efforts at two overrepresented groups, those with mental illness and our First Nation communities.  I suspect more fodder for the blog. 

Do your part, and submit something to the government supporting a positive approach to tobacco-free environments, supporting cessation, and developing directed strategies to work with First Nations and those afflicting by chronic mental illness.  

War on drugs - Canadian government once again pushing mandatory sentences

Bill C-10 was introduced into government on September 20^th.  It follows the typical government approach of using omnibus legislation to change numerous acts, and preclude substantive discussion on individual issues.

Not surprising, the concept of mandatory minimum sentences for certain drug offences has been reintroduced, and with a majority government, expect this to sail through government without barriers this time.   Bill C-10 section 41

This blog has raised the issue previously War on drugs - your wallet is the loser  and certainly groups like the Urban Health Research Initiative have actively led the opposition to previous legislative efforts UHRI home page  .

The supposed intent of the legislation is to enhance the war on drugs, in particular as relates to distribution of drugs.  The effect has been demonstrated in the US and other countries as having no benefit, overcrowding jails, increasing costs for correction services  and not reducing drug utilization.  

Note that anyone caught with five plants of cannabis, has the potential to be incarcerated for a minimum of 6 months if the courts can be convinced that the plants were to be used for distribution and not personal consumption.  That there is an onus to demonstrate intent to traffic is an improvement over the previous iterations of the legislation – but get real. 

It is the fourth time these sections have been introduced in legislation and always with significant opposition.  When will this government listen to evidence and to justice and health professionals instead of remaining stoically entrenched in archaic ideology.

It is time to annoy your MP on this one and raise the bar of opposition.  

Social support - the forgotten determinant of health

Please send messages to drphealth@gmail.com, and follow on twitter @drphealth

How many of you have a friend that you can confide in? Someone who’s advice you can trust? Someone that you can depend upon if in a crisis?  Chances are if you are reading this blog that the rate is almost 100%.   Have you considered how your personal lifestyle protects your health and how privileged you are relative to the determinants of health?

 Up to 20% of the population are not able to respond affirmatively to the questions of who they can look to when in need.   Such social support networks were clearly identified in the 1994 Determinants of Health document, and the cross fertilization of social scientists and epidemiologists led to much better definition of what social support entailed. With this came a migration of language noticable in the  "social" determinants of health to 'social inclusion and exclusion' and 'contribution of the social economy'.  These items were detailed in two resource papers that are worth reading Social inclusion PHAC backgrounder and social policy PHAC backgrounder

Social inclusion/exclusion denotes the health impacts associated with recent immigrants, discrimination, linguistic exclusion and addressing issues related to institutional, workplace, and community ways of limiting these exclusionary barriers.  The backgrounder however does not speak to the “wellbeing” afforded by increasing communality, friendship, and collaboration.  These constructs have been interwoven into how the education system engages students and will likely redefine community, business and social relationships in the future (hopefully in a healthy fashion).

The social economy component comes from a well entrenched Quebec rhetoric and might better be translated as the “non-government (NGO) sector”.   Other terms include “voluntary” sector, the “third” sector, “non-profit” (amongst other terms).  It is the huge contribution that the social economy provides to enhancing wellbeing in the population.  While components are formalized, must of the social economy is through informal networks. 

Regrettably, Governments have looked past the contribution of this sector and over the past decade have substantively reduced funding to the NGO sector. The long term implication of such undermining of the social economy has not yet been seen, and unlikely being evaluated. Nor is there a vibrant discourse on the implications or resilience of the social economy to respond to this brutal attack.  

A challenge to any reader to try to find government statistics on total funding to any NGO sector, but most specifically to the health NGO community and how this has changed since 1990 or 2000.   Please let me know at drphealth@gmail.com   Such massive reductions desire being unmasked and the consequences of policy shifts made transparent.

The flaw in the migration to the newer "social" determinants has actually been that the population level interpretation has diluted the individual level measures.  The original determinants spoke of the protective health effects being correlated with the number of friends, with marital status, personal assistance in dealing with adversity, problem solving and mastery and control of life circumstances.  These individual level attributes have been lost and yet remain central to the discourse on determining what keeps us healthy. The background papers likely led to the inclusion of the "social environment" as one of the added determinants after 1994, but the dialogue on social support networks has disappeared.

The divergence of interpretations has added to the richness of our understanding of one of the lesser appreciated and understood of the determinants.   It begs the question of how newer technology in texting, tweeting and blogging will compromise or potentially enhance social support networks – those technologies weren’t even imagined in 1994 and emailing was still a relatively limited commodity. There is a topic for a future blog. 

Homelessness - who is benefiting from programming?

About 1 in 200 people in North America are without a home.  Depending on how one wants to define homelessness, these numbers are more likely two to three times higher.

In the extreme incidence of homelessness, individuals may not be able to receive subsidy checks, open bank accounts, get health care because of lack of a free insurance number, or obtain any form of identification because of a lack of address.  Not only are they homeless, but they become almost invisible to a system that is dependent upon identity to function. The gradient extends across the UNs criteria for housing which include; the shelter must protect the occupants from the elements, provide safe water and sanitation, provide for personal safety, and the criteria extend to being located near employment, education and health care, and be affordable.

Those that have permanent housing that erodes a significant portion of monthly income (>30% but realistically some are over 80% of costs going to housing) are considered at-risk for homelessness. Considerably more individuals live a “street oriented” lifestyle, which frequents public locations for social benefit and may extend to activities that supplement incomes (including sexual services), or as coping mechanisms for certain addictions. About 70% of street oriented youth have attempted to escape situations of physical or sexual abuse in their homes. 

Roughly ½ of homeless persons have a chronic mental illness.   Half have challenges with substance addictions (a proportion struggle with both).   “Homeless persons” are at risk for being victims of violence, higher rates of infectious disease, higher rates of certain chronic illnesses.  They often require hospitalization more frequently and are at a significantly increased risk of death from a variety of causes, including extremes of temperature. 

Between 1999 and 2007, Canada had a National Homeless Initiative designed to provide for the fundamental need of shelter.  This changed under current government to a Homelessness Partnering Strategy which supposedly provides funding for community initiatives through to 2014 Homelessness partnering strategy .  It is an interesting exploration to try to find more information and determine what successes are being achieved.  While there are anecdotal stories of contributions to local initiatives, one has to wonder where the dollars are going and who is benefiting?   Seems like an excellent program for the Auditor General to try review to determine what and how well dedicated funds are actually benefiting persons on the street. The full program is supposed to provide an additional $1.5B – that amounts to about $8500 per homeless person in the country, presumably it should be make a huge difference, but somebody please tell me where the transparency is in how the money is being spent and what value is to be accrued. There is political currency is being seen as generous to the homeless population, but lets hold the political bodies accountable to deliver.

In the meantime local communities have often responded, not driven necessarily by altruistic motives to help the least fortunate of our communities, but often driven by economic concerns of addressing deteriorating urban core areas where businesses are struggling and perceive homeless persons as a impediment to attracting buying consumers to their shops. 

Homelessness is a real problem, something that requires dedicated and concerted effort to address and accountability for measuring success.   Ask your local, provincial and federal leaders what has been done and how has the money been spent?